Letters Never events revisited

Learning from Jacintha Saldanha’s death

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f152 (Published 22 January 2013) Cite this as: BMJ 2013;346:f152
  1. Rajan Madhok, medical director1
  1. 1Kleyn Healthcare, Warrington WA2 7JQ, UK
  1. rajan.madhok{at}btinternet.com

Royal nurse Jacintha Saldanha’s suicide highlights the immense pressure felt by healthcare workers (HCWs) when involved in serious incidents. Wu previously raised awareness of the “second victim phenomenon,” whereby HCWs experience serious functional impairment, with some leaving their profession and a few committing suicide.1

During its annual conference in November, the British Association of Physicians of Indian Origin (BAPIO), passed a motion asking that suicides by HCWs while undergoing investigations should be treated as a “never event.”2

The decision was informed by General Medical Council data showing that 92 doctors have died during the past eight years while being investigated—with at least three having committed suicide—and personal experiences of many doctors who suffered considerable anxiety and stress when faced with complaints.

As with other never events, details about how to manage them, including what support should be provided, will need to be clarified. The benefits of such a designation would be the heightened awareness, the introduction of systems to minimise these events, and the subsequent learning.

The US poet and physician Williams Carlos Williams described a doctor as “one upon whom we set our hopes when ill and our dogs when well,” and the way things are in the NHS many HCWs can identify with this. Therefore, creating this new never event will go some way towards supporting HCWs and a long way towards improving patient safety.


Cite this as: BMJ 2013;346:f152


  • Competing interests: RM is the chairman of BAPIO and until 31 Dec 2012 was on the GMC council. He thanks Clare Gerada for a useful discussion on never events and Sudheer Surapaneni for the GMC data.

  • The full rapid response is at www.bmj.com/content/342/bmj.d1263/rr/620875.